As recently as 2016, José Carlos Millán Calenti, along with his colleagues from the Gerontology Research Group, Department of Medicine, at the Universidade da Coruña, in Spain, conducted a systematic review of randomized controlled trials (RCTs), focussing on the non-pharmacological management of agitation, specifically of Alzheimer’s patients, with the aim of making evidence-based recommendations about the use of specific intervention strategies. Of all the other non-pharmacological methods assessed – including cognitive stimulation/training, behavioural interventions, physical exercise, therapeutic touch, aromatherapy and bright light therapy – music therapy stood out as one of the most promising and profound.
The results were particularly visible when the intervention was geared specifically for a particular individual. In other words, maximum benefit was obtained when music that categorically related to evoking positive memories unique to a patient was played, opposed to any generic versions for the entire group in context. Equally strong results were obtained when the music was interactive, beckoning active participation with clapping, singing and dancing.
The researchers used a standard and popular scale to assess agitation: the BEHAVE-AD. It covers behavioural symptoms in seven categories: paranoid and delusional ideations; hallucinations; activity disturbances; aggressiveness; diurnal rhythm disturbances; affective disturbances; and anxieties and phobias (a higher score indicates more severity). The researchers probed the long-term effects of passive (listening to music from a CD player) or interactive (including clapping, singing and dancing) music therapy, lasting for ten weeks.
A higher, long-term reduction was observed in behavioural symptoms in the interactive music group, compared with the passive music group and no-music control group, which received the usual care rendered.
The music facilitators included two music therapists, four occupational therapists and six nurses. Each intervention was performed once a week and lasted 30 minutes. Individualized music was selected, related to specific positive memories for each participant
The results were gratifying but not surprising, as the scores of five items of the BEHAVE-AD – paranoid and delusional ideations, activity disturbances, aggressiveness, affective disturbances, and anxieties and phobias – were significantly reduced in the group with interactive music.
How long did these positive benefits sustain? Sure enough, as this experiment showed, the effects on decreasing agitation did not last long, with benefits dwindling progressively and eventually disappearing, after three weeks from the cessation of the interventions.
What does all this indicate? It simply shows that the effects are contingent on the active involvement of the patients concerned – just like, we may add, the good effects of a company-driven drug. We scientists walk the same paths here, except in the glorious differences relating to adverse effects and tolerance – both of which are the perilous effects of a prescribed pill.
These results also revisit a fundamental concept of music therapy, or for that matter, any non-pharmacological therapy. When it comes to the treatment or management of cognitive disorders, the approach needs to be patient-centric. We remind ourselves again and again that every Alzheimer’s disease is different, just as every individual is unique.
Intriguingly, more than MDs, nurses have championed the use of music therapy as an indispensable intervention for patients with dementia and allied cognitive disorders. In an article, author H. Ragneskog, among others, described the reactions of five patients with dementia to three different types of music during dinner. The entire episode was filmed. One of the study’s restless patients showed decreasing agitation, and the other patient actually fed himself more than usual, while in general, all patients preferred to spend more time on the dinner table as the music lingered.
These reactions hit the very core of medical research – in terms of incorporating holistic options within the framework of standard innovations. The situation only became stickier when it approached the idea of music as therapy.
As I have hinted earlier, the problem lies in our mindset. It is useless to force down one’s throat the trademark trials and tribulations to which a drug is subjected, for music is not a drug. It is an internal feeling, a subjective choice, a mood elevator that is at once personal and momentary. I say momentary only because the same piece of music that comes as rejuvenating, refreshing and reviving can turn passé, dispensable and ordinary at another time of day or in another mood. In other words, we are caught between “music over mind” versus “mind over music”. While certain music has been shown to have the capability of taming the untamed, for most individuals, receptivity of the mind takes precedence over music, per se. We go overboard trying to demonstrate the benefits of music without having the knowledge or understanding of how it actually works and achieves its outcomes.
“But it works!” Andrew DeNicola bellowed to me when I asked him about the benefits of music. Affiliated for more than 30 years with JP Steven High School in Edison, New Jersey, DeNicola received a nomination for a Grammy Award as a music teacher.
“How do you think music helps your students, or yourself, for that matter?” I asked, sitting in his office with him, while his students rehearsed.
“Simply put, it relieves the stress,” he said. “I see these students. Their nerves are shot. But when they come to me, and when they play with me, they are instantly calmed. Something happens. I don’t know what.”
From coma to home: The fascinating case of Dawn Shilling
Dawn Shilling was a 22-year-old patient who was admitted to our hospital in a state of complete unresponsiveness, due to a drug overdose after a fight with her boyfriend. The Glasgow Coma Scale, the standard neurological scale to assess a patient’s conscious state, read 5 out of 12. Neurologists ordered an MRI of her head, which showed features suggesting anoxic encephalopathy. She remained bed-bound, on mechanical ventilation and essential comfort medicines. With no meaningful expectations, our hospital neurologist called her family members to explain the future course of action. The idea was to get her family’s opinion for either continued therapy or withdrawal of active care. Accordingly, the Bioethics Committee was summoned.
It was explained in painful detail how Dawn would remain bedridden and tied to ventilation with little to no chance of meaningful recovery. All family members, except John, her father, agreed to the futility of further care. John was a retired construction worker who had bent over backwards to raise his children. After his wife had died of a sudden stroke, his daughter was all he lived for, and he refused to budge, despite social workers, clinicians and other family members trying to convince him.
Active management continued, despite the administrative eyebrows that continued to be raised with each passing day. I shifted Dawn to a quieter room, away from the hustle and bustle of the central nursing station. I saw no reason for meaningless weather channels and TV soap operas in her room and recommended Gospel music, much to the delight of her father, who was a religious man and remained steadfast day and night by her bedside, half-reclined on an armchair. I told him to talk and read scriptures to Dawn as if she was listening. He did so with unfailing devotion.
Nothing happened and nothing moved. We maintained the ventilation management, the PEG (percutaneous endoscopic gastrostomy) tube feeding, the IV fluids and the Gospel music. One day, John called me late one evening, his voice trembling.
“I think I saw Dawn’s eyes roll over. And her fingers trembled. Maybe she is communicating?”
I did not have the heart to tell him that those could be natural movements, periodic and involuntary reflexes. The following morning, on my rounds with my residents, I tried something different. I lowered my voice, and slid my ungloved index finger into Dawn’s half-crumpled palm and whispered to her, “If you can hear me, Dawn, squeeze my finger.”
After what seemed like forever, Dawn’s fingers quivered, subtle and slight, almost in protest. I looked up at John, who stood at the other end of the bed, his lips trembling, his eyes a raging river of tears. I knew the battle was far from over. I wanted nothing to change, I wanted traditional medicine to stay back, with the gospel and John sustaining the moment.
Dawn recovered, muscle by muscle, motion by motion. One morning, she moved her eyes. One afternoon, she consumed her first liquid diet in two months. A month later, she was wheeled out of Room No. 516, followed by 20 joyous family members.
Did Dawn recover naturally? Was she an exception to the rule? Did John’s soothing words, day in and day out, unplug Dawn’s clogged brain? Did the relentless gospel music awaken her comatose brain?
We do not have answers to any of these questions. We do know that Dawn turned around – against all medical dictates. We do know that other than ventilation management and PEG tube feeding, no other medical intervention was offered. And we know that the room was flooded with music of the most profound depth and demeanour.
We will do well to keep our perspectives right here. The worst we can do is place Dawn’s personal experience among other comatose patients, play gospel music and search for statistical significance.
We over-glorify facts and figures while the magic of personal healing gets demonised as exceptional and coincidental. More objectively, music becomes that unseen bridge across which memories, dead and defunct, become recollections, viable and visible.
Excerpted with permission from The Fight Against Alzheimer’s: How to Prevent, Cure, Care, and Find Hope, Shuvendu Sen, Rupa Publications.